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American Journal of Dermatology and Venereology 2013, 2(4): 39-41

DOI: 10.5923/j.ajdv.20130204.01

Eosinophilic Folliculitis (Ofuji's Disease) and Mucosal


Involvement, in Association with Helicobacter pylori in
Sudanese Patient
Adil H. H. Bashir1,*, Lamyaa A. M. Elhassan2, Abdel Khalig Muddathir1,
Khalid O. Alfarouk1, Ahmed M. El Hassan1

1
University of Khartoum, Khartoum, Sudan
2
Ahfad University for Women, Omdurman, Sudan

Abstract Eosinophilic Folliculitis (EF) is a rare dermatosis and the treatment is difficult because the underlying
pathogenic mechanism is unknown. We reported rare case, 4 years duration of Eosinophilic Folliculitis (EF), of married
female patient, fifty years old, presented with insidious onset of skin colored and slightly pigmented, discrete widespread,
clustered and diffuse non itchy, papulo-pustular lesions with central erosions and crustation, mainly at axillae, sub mammary,
and right nasal fold. Vermilion shows to be dry, fissure and crusted, with chronic dyspeptic symptoms. The cases were
diagnosed and confirmed histopathologically as Eosinophilic Folliculitis with Helicobacter pylori test positive, considered to
be the first case of EF been reported in Sudan and as a mucosal one in particular.
Keywords Eosinophilic Folliculitis, H. pylori, Immunology

infancy with associated eosinophilia[4]. Eosinophilic


1. Background pustular folliculitis in children is a rare follicular
inflammatory dermatosis, usually occurring early in life. The
Eosinophilic folliculitis (EF), also known as Eosinophilic disease progresses in flares of prurigenous plaques studded
pustular folliculitis or sterile eosinophilic pustulosis, is a rare with papules and sterile pustules of the scalp and other areas
follicular pruritic papular eruption observed in association of the skin. The mucosal involvement seen in patients in one
with human immunodeficiency virus (HIV), though it can study has never been reported in the literature neither in the
occur in HIV-negative individuals where it is known by the infancy nor in the adult form[5].
eponym Ofuji disease (OD)[1]. OD or eosinophilic pustular folliculitis and human
Eosinophilic pustular folliculitis is a rare but important immunodeficiency virus-associated eosinophilic folliculitis
disease entity presenting with recurrent indurated (HIV-EF) both show eosinophil -rich folliculocentric
erythematous papulopustular and plaques on the face. infiltrates, and it is not clear whether they are distinguishable
Increased awareness of this condition is important as it can pathologically. So it is suggested that OD and HIV-EF are
mimic many other conditions presenting as red plaques on indistinguishable pathologically and the diagnosis requires
the face[2]. clinical correlation. Follicular Mucinosis (FM) was not
The diagnosis of EF is based on the histologic findings uncommonly seen in lesions of OD. OD with FM may be
consisting of a sterile inflammatory infiltrate rich in difficult to differentiate from FM, especially in cases
eosinophils involving hair follicles. EF in HIV patients is presenting with non-annular or non-pustular lesions, but the
believed to be an immuno inflammatory response directed diagnosis might be facilitated by finding eosinophil-rich
either at follicular or skin flora antigens in the late-stage of pustule, microabscess, or infiltrate in pilosebaceous units
HIV infection. In this stage, immune response is microscopically[6].
characterized by a shift from a Th1- to a Th2-dominant EF has been to occur in a patient affected by Hodgkin
cytokine profile and an increased secretion of interleukin-4 lymphoma[7]. Eosinophilic pustular folliculitis can be
and interleukin-5, both known to promote eosinophilia[3]. induced by allopurinol and timepidium bromide[8].
OD is an uncommon generalized pustular dermatosis of Eosinophilic pustular folliculitis associated with parasitic
infestations in some cases[9]. The histopathology of
* Corresponding author:
Derma55@yahoo.com (Adil H. H. Bashir) folliculitis in HIV-infected patients is protean. No single
Published online at http://journal.sapub.org/ajdv factor could be identified as the cause, making targeted
Copyright 2013 Scientific & Academic Publishing. All Rights Reserved antibacterial or antifungal therapy unlikely to be successful
40 Adil H. H. Bashir et al.: Eosinophilic Folliculitis (Ofuji's Disease) and Mucosal Involvement,
in Association with Helicobacter pylori in Sudanese Patient

across a wide range of patients[10]. show hyperkeratosis, Acanthosis, spongiosis and follicular
Helicobacter pylori infection leads to gastritis, duodenal plugging (Figure 1). The hair follicles are dilated and contain
or gastric ulcer and even in rare cases to gastric carcinoma or a dense collection of eosinophils with few neutrophils in
Mucosa Associated Lymphoid Tissue (MALT) lymphoma. some follicles (Figure 2). The surrounding dermis shows
Based on a number of reports, a possible relationship of H. lymphocytic and plasma cell infiltration. The diagnosis was
pylori infection to a variety of different dermatosis has been Eosinophilic Folliculitis.
suggested, including urticaria, rosacea, acne rosacea, atopic
dermatitis, alopecia areata, Sjgrens syndrome, Schnlein -
Henoch purpura, and Sweets syndrome[11].

2. Case Report
A female patient, married, 50 years old, house wife,
descent from second degree relative parents, resident in Dar
Alsalam, belongs to Noba tribe (Darker Skin).
The condition started 4 years ago with insidious onset and
progressive course, with skin colored widespread diffuse and
discrete non itchy, papulo-pustular lesions, with central
erosions and crustation, mainly at axillae, sub mammary, and Figure 1. Shows follicular plugging (H&Ex40)
right nasal fold. Vermilion show to be dry, fissure and
crusted. The condition is not associated fever or any
constitutional manifestations rather than chronic dyspeptic
symptoms.

3. General Examination
The general condition is good, not pale, not icteric, as well
no palpable spleen, and liver. No palpable lymph nodes.

4. Dermatological Examination
On dermatologic examination of the patient, widespread, Figure 2. Shows eosinophils in the lumen of a follicle. The epithelium
clustered symmetrically distributed erythematous centrally lining the follicle shows spnogiosis (H&Ex40)
eroded and crusted papulo-pustular lesions; firm and tender. The patient was negative for both HIV and VDRL. Using
Skin overlying fixed, and hyperpigmented. Lesions size ICT, Helicobacter pylori infection was reactive. The blood
varies from 0.5-1cm, involving mainly axillae, sub group of the patient was O positive.
mammary, and right nasal fold. Lower lip vermilion found to
Immunological investigations:
be dry, eroded, fissured and crusted with swollen,
erythematous and slightly eroded lower lip mucosal surface. HIV screen test: Negative
Similar lesions were seen on both soles and palms. No VDRL test: Negative
dystrophy was noticed on nails, also no abnormality was H. Pylori ICT test: Reactive
detected in ears nor hair. On oral cavity examination, the Blood group: O positive
lower lip mucosa was swollen and slightly eroded with All investigations have been done for the possible
fissured tongue. underlying cause shown to be negative otherwise H. pylori
Palms and soles: Similar lesions at both soles and palms. test which showing to be reactive.
Nails: No nails dystrophy has been noticed.
Ears: No Abnormality Detected.
Hair: No Abnormality Detected. 6. Treatment
Oral cavity: lower lip mucosa swollen and slightly eroded
Good response has been noticed where patient received
with fissured tongue.
first line triple therapy, as Doxycyclin 100 mg bid for 10
days, Cefixime 400 mg for 5 days and Rabeprazol as proton
5. Investigations Done pump inhibitor (PPI) 20 mg for 28 days. After that, H. Pylori
stool Ag test has been done to show antigen was not
In skin biopsy taken from upper chest, the lesion showed detected.
American Journal of Dermatology and Venereology 2013, 2(4): 39-41 41

7. Discussion Australas J Dermatol 2003; 44(1), 44-7.

Eosinophilic Folliculitis is a quite rare presentation [3] Teofoli P, Barbieri C, Pallotta S, Ferranti G, Puddu P. Pruritic
eosinophilic papular eruption revealing HIV infection. Eur J
especially in Africans and underlying pathogenic mechanism Dermatol 2002; 12(6), 600-2.
is unknown[12]. The mucosal involvement seen in patients
in one study has never been reported in the literature neither [4] Mengesha YM, Bennett ML. Pustular skin disorders:
in the infancy nor in the adult form[5] as seen in this case diagnosis and treatment. Am J Clin Dermatol 2002; 3(6),
389-400.
Our case had an adult onset of presentation. Clinical
features and histopathology were typical; it was associated [5] Boudaya S, Turki H, Bouassida S, Khemakhem M, Marrakchi
with H. Pylori, patient showed good response to triple S, Zahaf A. Eosinophilic pustular folliculitis in infancy: an
therapy. where focus as possible antigen is of paramount unusual case. Ann Dermatol Venereol. 2003; 130(4), 451-4.
concern as possible causative antigen as in this case all [6] Lee JY, Tsai YM, Sheu HM. (2003). Ofuji's disease with
serological specific tests for EF were negative while H. follicular mucinosis and its differential diagnosis from
Pylori ICT test was the only positive test and turn negative alopecia mucinosa. J Cutan Pathol. 30(5), 307-13.
after taken specific treatment (triple therapy), with no [7] Vassallo C, Ciocca O, Arcaini L, Brazzelli V, Ardigo M,
remission. Lazzarino M, Borroni G. Eosinophilic folliculitis occurring in
a patient affected by Hodgkin lymphoma. Int J Dermatol 2002;
41(5), 298-300.
8. Conclusions [8] Maejima H, Mukai H, Hikaru E. Eosinophilic pustular
folliculitis induced by allopurinol and timepidium bromide.
Response of Eosinophilic Folliculitis to triple therapy as H. Acta Derm Venereol 2002; 82(4), 316-7.
pylori considered to be a possible causative underlying cause
and as it had been known that a definite cause was not clear [9] Opie KM, Heenan PJ, Delaney TA, Rohr JB. Two cases of
and no specific treatment was known to be effective, so in eosinophilic pustular folliculitis associated with parasitic
infestations. Australas J Dermatol 2003; 44(3), 217-9.
this case it might focus new era to diagnose and treat EF as
difficult one to be treated. [10] Holmes RB, Martins C, Horn T. The histopathology of
folliculitis in HIV-infected patients. J Cutan Pathol 2002;
29(2), 93-5.
[11] Bashir AH, Yousif SM, Mahmoud MOA. Clinicoepidemiolo
gical study in Sudanese patients, Prevalence and effect of
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